THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. If you have any questions or need any additional information about this Notice of Privacy Practices (Notice”), please contact Grossnickle Eye Center, Inc.’s Contact Person at (574) 269-2777

A. GEC’S DUTIES

Grossnickle Eye Center, Inc. (“GEC”) is required by the final Standards for Privacy of Individually Identifiable Health Information (the “Privacy Standards”) to maintain the privacy of your protected health information. In addition, GEC is required by law to provide you with adequate notice of GEC’s uses and disclosures of your protected health information, notice of your rights with respect to your protected health information, and notice of GEC’s legal duties with respect to your protected health information. This Notice is given to you to satisfy GEC’s legal obligations to provide adequate notice to you. GEC agrees to abide by the terms of its Notice then in effect.

GEC is required to give this Notice to you no later than its first delivery of services to you on or after April 14, 2003 (if the first service delivery to you is delivered electronically, GEC will provide electronic notice of its privacy practices automatically and contemporaneously in response to your first request for service). In addition, GEC is required to make its Notice available to you at any time upon your request, and to post the Notice in a clear and conspicuous location in the waiting room of each of GEC’s offices. GEC has a website at: gecenter.com. A copy of this Notice will be posted on that website and a copy of the Notice will be available electronically through the website.

For purposes of the Privacy Standards and this Notice, the term “protected health information” means “individually identifiable health information”. The term “individually identifiable health information” means health information (whether oral or recorded in any form or medium), including demographic information collected from you, that identifies you, or could reasonably be used to identify you and which: is created or received by a health care provider, health plan, public health authority, employer, life insurer, school or university, or health care clearinghouse; and, relates to your past, present, or future physical or mental health or condition, the provision of health care to you, or the past, present, or future payment for the provision of health care to you.

B. How GEC May Use or Disclose YOUR Protected Health Information

As a general rule, GEC may not use, disclose or request protected health information about you except as required or permitted by the Privacy Standards. Furthermore, except in limited circumstances, GEC must use, disclose or request only the minimum necessary protected health information to accomplish the purpose of the use, disclosure or request.

1. Required Disclosures. The following categories describe the instances in which GEC is required to disclose your protected health information:

● To You. GEC is required to disclose protected health information about you to you when requested by you in certain circumstances. Pursuant to the Privacy Standards, you have the right to request access to your protected health information for inspection and copying purposes and to request an accounting of disclosures. Each of those rights in discussed in more detail in the “Your Rights Regarding Protected Health Information About You” section of this Notice.

● To the Secretary. GEC is required to disclose protected health information to the Secretary of the Department of Health and Human Services when the information is required in order for the Secretary to investigate or determine whether GEC is in compliance with the Privacy Standards.

2. Permitted Uses and Disclosures. The following categories describe the instances in which GEC is permitted to use and disclose protected health information about you without obtaining your written authorization. For each category, GEC has attempted to explain what it means and has given examples. Not every use or disclosure in a category will be listed. However, all of the ways GEC may use and disclose information without authorization will fall within one of the following:

● Treatment. GEC may use your protected health information to provide you with medical treatment or services. GEC may disclose protected health information about you to doctors, nurses, or other health care professionals who are involved in taking care of you. For example, GEC may be treating you for diabetes. If you break your leg, GEC may refer you to another doctor to treat you for your broken leg. That doctor may need to know that you have diabetes as diabetes may slow the healing process. GEC may disclose information about your diabetes to the doctor treating you for your broken leg.

● Payment. GEC may use or disclose your protected health information for purposes of receiving payment for treatment and services you receive. For example, GEC may give your insurance company information about your treatment so the insurance company will pay GEC or reimburse you. GEC may also tell your insurance company about treatment you are going to receive to determine whether your insurance company will pay for it.

● Health Care Operations. GEC may use and disclose protected health information about you for operational purposes. For example, your protected health information may be disclosed to GEC’s health care professionals to evaluate the performance of the health care professionals, to assess the quality of care and outcomes in your cases and similar cases, to learn how to improve GEC’s facilities and services, and, to determine how to continually improve the quality and effectiveness of the health care GEC provides.

● Incidental Uses and Disclosures. GEC may use and disclose protected health information about you incident to a use or disclosure permitted or required by the Privacy Standards so long as GEC has complied with the minimum necessary and safeguards requirements imposed under the Privacy Standards. For example, GEC’s nurses may discuss information about your care at the nursing station, and if someone overhears that discussion, the disclosure to that person will be permitted so long as the nurses discussed only the minimum necessary and GEC took appropriate steps to put safeguards in place. Two other examples are GEC may use are patient sign-in sheets and calling patients by their first and last name, in our waiting room, to identify the correct patien

● Appointment Reminders. GEC may use and disclose protected health information about you to contact you as a reminder that you have an appointment, you have missed an appointment, or need to re-schedule appointment for treatment or medical care. The appointment reminder may be via phone (including a voice message), mail (including a reminder postcard), email or otherwise.

● Treatment Alternatives. GEC may use and disclose your protected health information to tell you about or to recommend possible treatment options or alternatives that may be of interest to you so long as GEC is not receiving financial remuneration in exchange for making the communication

● Health-Related Benefits and Services. GEC may use and disclose your protected health information to tell you about health-related benefits or services that may be of interest to you so long as GEC is not receiving financial remuneration in exchange for making the communication..

● Fundraising Activities. GEC may use protected health information about you to contact you in an effort to conduct fundraising activities. With each fundraising communication, GEC must provide you with a clear and conspicuous opportunity to elect not to receive any further fundraising communications.

● Business Associates. GEC contracts with others outside of GEC’s organization to perform or assist GEC in performing functions that involve the use and disclosure of protected health information. For example, GEC may contract with a billing company to do billing for GEC. The billing company will need protected health information in order to perform its job. As such, GEC may disclose protected health information about you to business associates of GEC so that the business associates can perform the job GEC has asked them to do. In order to protect your protected health information, GEC will require all of its business associates to make assurances to GEC they will each appropriately safeguard your protected health information. Further, business associates will be required to report to GEC any breaches with respect to your information about which they know or in the exercise of reasonable diligence should know.

● Individuals Involved in Your Care. In certain circumstances, GEC may use or disclose protected health information about you to a family member, relative or close personal friend who is involved in your medical care. In addition, GEC may disclose protected health information about you to notify or assist in the notification of a family member, relative or close personal friend who is involved in your medical care of your condition, location and status.

● Disaster Relief Efforts. In certain circumstances, GEC may use or disclose protected health information about you to a public or private entity authorized by law to assist in disaster relief efforts for the purpose of coordinating with such entities.

● Personal Representatives. Except in limited circumstances, GEC must treat a personal representative of a decedent as the individual about who the protected health information relates. As such, GEC may disclose protected health information to your personal representative.

● Adults and Emancipated Minors. If a person has authority to act on behalf of an adult or an emancipated minor in making decisions related to health care, GEC must treat that person as a personal representative. As such, except in limited circumstances, GEC may disclose protected health information to your personal representative as if the disclosure was being made to you.

● Unemancipated Minors. If, under applicable law, a parent, guardian or other person acting in loco parentis has authority to obtain access to protected health information about an unemancipated minor, then GEC may disclose protected health information to the person acting in loco parentis as if the disclosure was being made to the unemancipated minor.

● Required by Law. GEC will disclose protected health information about you when it is required to do so by federal, state or local law, rule or regulation. For example, GEC may disclose information for the following purposes: for judicial and administrative proceedings pursuant to legal authority; to report information related to victims of abuse, neglect or domestic violence; and, to assist law enforcement officials in their law enforcement duties.

● Public Health/Health Oversight. GEC may use or disclose protected health information about you for public health activities such as assisting public health authorities or other legal authorities to prevent or control disease, injury, or disability, or for other health oversight activities.

● Organ/Tissue Donation. GEC may use or disclose protected health information about you for cadaveric organ, eye or tissue donation purposes.

● Research. GEC may use or disclose protected health information about you for research purposes. For example, a research project may involve comparing the health and recover of patients who received one medication to those who received another medication. All research projects are subject to a special approval process. Before GEC will use or disclose protected health information about you, the project will be approved through the special approval process.

● Health and Safety. GEC may use or disclose your protected health information to avert a serious threat to the health or safety of you or any other person pursuant to applicable law.

● Specialized Government Functions. GEC may use and disclose your protected health information for military and veterans activities, for national security and intelligence activities, for protective services of the President and others, and to correctional institutions and other law enforcement custodial situations.

● Workers’ Compensation. GEC may use and disclose protected health information about you for workers’ compensation or similar programs to the extent authorized by and to the extent necessary to comply with laws regarding said programs.

● FDA Reporting. In the event GEC is subject to the jurisdiction of the federal Food and Drug Administration with respect to a product or activity for which GEC has a duty to make reports of quality, safety or effectiveness, GEC may use and disclose protected health information about you to make any fulfill any requirements imposed by the FDA.

3. Uses and Disclosures For Which Authorization is Required. The following categories describe the instances in which GEC may only use and disclose protected health information about you after first obtaining your written authorization:

a. All Instances Except as Required or Permitted. Except as required or permitted by the Privacy Standards, GEC may not use or disclose protected health information about you without your written authorization. When GEC receives your authorization to use or disclose your protected health information, GEC must make its use and disclosure consistent with such authorization. If you provide GEC authorization to use or disclose your protected health information, you may revoke that authorization, in writing, at any time. If you revoke your authorization, GEC will no longer use or disclose your protected health information for the reasons covered by your authorization. However, your revocation will not be applicable to disclosures that GEC already made prior to its receipt of your written revocation.

b. Psychotherapy Notes. GEC may not use and disclose psychotherapy notes without your authorization except: to carry out certain treatment, payment and health care operation activities; as required by law; for health oversight activities; to coroners and medical examiners; and, to prevent or lessen a serious and imminent threat to the health and safety of a person or the public.

c. Marketing. GEC may not use and disclose protected health information about you for marketing without your authorization. Marketing means a communication about a product or service that encourages the recipient of the communication to purchase or use the product or service. Marketing does not include a face to face communication made by GEC to you and/or a promotional gift of nominal value provided by GEC. Marketing also does not include refill reminders or other communications about drugs, communications to recommend alternative treatments for you and/or communications to describe health-related product or services, so long as GEC is not receiving any financial remuneration in exchange for making the communication.

d. Sale of PHI. GEC may not use and disclose PHI about you if such use or disclosure is a sale of PHI, without your authorization. Your authorization must state that you acknowledge that the disclosure will result in remuneration to GEC.

C. YOUR RIGHTS REGARDING PROTECTED HEALTH INFORMATION ABOUT YOU

You have the following rights regarding protected health information GEC maintains about you:

1. Request Restrictions. You have the right to request that GEC restrict or limit how it uses or discloses your protected health information for treatment, payment or health care operations. GEC will consider your request, but GEC is not generally required to agree to your request. Notwithstanding the foregoing, GEC must agree to your request to restrict disclosure of PHI about you to a health plan if: the disclosure by GEC is for payment or health care operations and is not otherwise required by law; and, the PHI to be restricted relates only to a health care item or service for which you have paid GEC in full. GEC cannot agree to limit uses and disclosures that are required by the Privacy Standards. If GEC agrees to your request, GEC will comply with your request unless the information is needed to provide you emergency treatment or in other limited circumstances. To request a restriction, you must make your request in writing to the Privacy Officer of GEC. In your request, you must provide GEC with your name, address, a specific description of the requested restriction, and the requested duration of the restriction. The request must also be signed and dated. Please refer to 45 C.F.R §164.522 for a more detailed description of your rights.

2. Request Confidential Communications. You have the right to request that GEC communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that GEC only contact you at work or by mail. To request confidential communications, you must make your request in writing to the Privacy Officer of GEC. In your request, your must provide GEC with your name, address, a specific description of the request, an identification of the alternate method of communication and/or alternate address, and the duration of the request. The request must also be signed and dated. GEC will not ask you the reason for your request and GEC will accommodate all reasonable requests. Please refer to 45 C.F.R §164.522 for a more detailed description of your rights.

3. Request Access to Inspect and Copy. You have the right to request access for purposes of inspecting and copying your PHI. To request access, you must make your request in writing to the Privacy Officer of GEC. In your request, you must provide GEC with your name, address, a description of the requested access (i.e., inspection, copying, both) and a statement as to the requested form or format of the information. GEC will provide the information in the form and format requested by you if it is readily producible in such form or forma, and if not, it will be provided in a readable hard copy form. The request must also be signed and dated. GEC will respond to your request within 30 days. If GEC is unable to respond within that time, GEC may have an additional 30 days if it notifies you in writing as to the reason for the delay and gives you the date on which it will respond. In some instances, GEC may deny your request to inspect and copy. If you are denied access to your PHI, you may request that the denial be reviewed in certain circumstances. If you are entitled to a review, another licensed health care professional chosen by GEC will review your request and the denial. The person conducting the review will not be the person who denied your request. GEC will comply with the outcome of the review. If you request a copy of the information, GEC may charge a fee for the cost of copying, mailing and other supplies associated with your request. Please refer to 45 C.F.R §164.524 for a more detailed description of your rights.

4. Request Amendments. If you feel that protected health information GEC has about you is incorrect or incomplete, you have the right to request that GEC to amend the information. You have the right to request an amendment for as long as the information is kept by or for GEC. To request an amendment, you must make your request in writing to the Privacy Officer of GEC. In your request, you must provide GEC with your name, address, a specific description of the requested amendment and a description of the reason or basis for the amendment. The request must also be signed and dated. GEC will respond to your request within 60 days. If GEC is unable to respond within that time, GEC may have an additional 30 days if it notifies you in writing as to the reason for the delay and gives you the date on which it will respond. In some instances, GEC may deny your request for an amendment. If GEC denies your request, you will be given the opportunity to submit a written statement of disagreement and/or request in writing that GEC include your request with any future disclosures of the affected information. In the event you file a written statement of disagreement, GEC will be allowed to prepare a written rebuttal. In some instances, the future disclosures of the affected information will include your request, the denial, your written statement and the rebuttal. Please refer to 45 C.F.R §164.526 for a more detailed description of your rights.

5. Request an Accounting of Disclosures. You have the right to request an accounting of disclosures describing certain of the disclosures GEC has made of protected health information about you. To request an accounting, you must make your request in writing to the Privacy Officer of GEC. In your request, you must provide GEC with your name, address, and a statement of the period of time for the accounting (which may not be longer than six (6) years and may not include dates before April 14, 2003). Your request should indicate in what form you want the accounting (for example, on paper, electronically, etc.) The request must also be signed and dated. GEC will respond to your request within 60 days. If GEC is unable to respond within that time, GEC may have an additional 30 days if it notifies you in writing as to the reason for the delay and gives you the date on which it will respond. The first accounting you request within a twelve (12) month period will be free of charge. For additional accountings during a twelve (12) month period, GEC may charge you for the cost of providing the accounting. GEC will notify you of the cost involved in advance and you may choose to withdraw or modify your request at that time before any costs are incurred. Please refer to 45 C.F.R §164.528 for a more detailed description of your rights.

6. Request Paper Copy of this Notice. You have the right to a paper copy of this Notice. You may ask GEC to give you a copy of this Notice at any time. Even if you have agreed to receive this Notice electronically, you are still entitled to a paper copy of this Notice. To obtain a paper copy of this Notice, contact the Contact Person of GEC

7. Receive Notification of Breach. GEC is required to provide notification to you and to the Secretary of the Department of Health and Human Services in the event GEC discovers a breach with respect to unsecured protected health information affecting you. The notification to you shall be made without unreasonable delay and in no case later than 60 days after the date the breach was discovered by GEC. The notice shall contain various information about the breach, including: a description of what happened and the date of the breach if known; a description of the types of information involved in the breach; any steps you should take to protect yourself from potential harm resulting from the breach; and, a brief description of what GEC is doing to investigate the breach, mitigate harm, improve security, and impose sanctions on offending individuals. The notification will be provided to you in writing by first class mail. If you have agreed to accept electronic notice, GEC may send the notification to you electronically. If GEC has insufficient or out-of-date contact information for you, the notification may be provided by other means, such as telephone or email. In some instances, GEC may be required to post a notice on its web site or post a notice in major print or broadcast media where you are likely to reside. In addition, GEC is required to notify the Secretary of the Department of Health and Human Services upon its discovery of a breach involving unsecured protected health information. If the breach involves 500 or more individuals, then the notification to the Secretary shall be made concurrently with the notice to affected individuals. If the breach involves fewer than 500 individuals, then the notice to the Secretary shall be made annually.

D. COMPLAINTS

If you believe your privacy rights have been violated, you may file a complaint. To file a complaint with GEC, contact the Contact Person of GEC at (574)269-2777. The Contact Person will inform you as to the formal procedure for filing a complaint with GEC and the Contact Person can assist you with respect to making a complaint. You will not be retaliated against for filing a complaint.

You may also file a complaint with the Secretary of the Department of Health and Human Services. To file a compliant with the Secretary of the Department of Health and Human Services, you should contact the Department of Health and Human Services at: The U.S.Department of Health and Human Services, 200 Independence Avenue, S.W., Washington, D.C. 20201; (877)-696-6775 within one hundred eighty (180) days of when you knew or should have known that the act or omission complained of occurred (this time limit can be waived by the Secretary for good cause shown)). You will not be retaliated against for filing a complaint.

E. CHANGES TO THIS NOTICE

GEC reserves the right to change its privacy practices and this Notice at any time. GEC will promptly revise and distribute a revised Notice whenever required by law or when there is a material change to: the uses or disclosures that may be made by GEC; your rights with respect to your protected health information; GEC’s legal duties; and/or GEC’s other privacy practices described in this Notice. GEC reserves the right to make the revised or changed privacy practices and Notice effective for protected health information GEC already has about you as well as any information GEC receives in the future.

GEC will post a copy of the current Notice in the waiting room of each of GEC’s offices. The Notice will contain on the first page, in the top center section, the effective date. In addition, each time you register at GEC’s office for treatment or health care services, GEC will make available to you a copy of the current Notice then in effect. GEC will also post a copy of its current Notice on its website at: gecenter.com.